Celiac axis compression syndrome. A critical review

Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block

PURPOSE

To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery.

MATERIALS AND METHODS

A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines.

RESULTS

CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events.

CONCLUSIONS

Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists

Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.

Acalculous Ischemic Cholecystitis Caused by Spontaneous Celiac Artery Dissection

We herein report a case of spontaneous isolated dissection of the celiac artery. A Japanese man in his 50s visited an emergency unit, complaining of sudden epigastralgia. Contrast-enhanced computed tomography indicated dissection of the celiac artery with patent false and true lumina, extending to the splenic and common hepatic arteries. On day 3 of hospitalization, the dissection progressed to the proper and right hepatic arteries. Progression of the dissection to the right hepatic artery provoked acalculous ischemic cholecystitis, and cholecystectomy followed. The resected gallbladder revealed extensive aseptic necrosis with little inflammatory reaction, and the gallbladder neck was spared from ischemia.

Median arcuate ligament syndrome (Dunbar syndrome)

Median arcuate ligament syndrome (MALS) is a rare condition which is due to the compression of celiac trunk by low riding of fibrous attachments of median arcuate ligament and diaphragmatic crura. Technically, MALS is a diagnosis of exclusion, consisting of vague symptoms comprising of postprandial epigastric pain, nausea, vomiting and unexplained weight loss. Different imaging modalities like Doppler ultrasound, computed tomography, magnetic resonance imaging and mesenteric angiogram are helpful to demonstrate celiac axis compression. The goal of treatment is decompression of celiac trunk either by open, laparoscopic or robotic method along with adjuvant interventional procedures like percutaneous transluminal angioplasty (PTA) and stenting. Surgical is the mainstay of treatment. This approach is based on open, laparoscopic or robotic release of compressed ligament along with celiac ganglionectomy and celiac artery revascularization. The role of interventional radiology is limited to angioplasty and stenting to open the stenosis rather than addressing the underlying compression of celiac trunk which has resulted in the symptoms. However, both the diagnosis and therapeutic intervention remains challenging. Extensive evaluation of etiology and pathophysiology of MALS and addressing the same through minimally invasive techniques may yield best prognosis in future. In this review article, we discuss briefly about the MALS in terms of etiology, diagnosis and its management including the role of interventional radiology.

Dunbar syndrome: An unusual cause of chronic postprandial abdominal pain

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare condition in which the celiac artery is compressed by the median arcuate ligament of the diaphragm. We hereby report a case of a 48-year-old female presenting with long-standing abdominal pain and ninety-pound weight loss who was found to have median arcuate ligament syndrome after extensive workup.

[Laparoscopic decompression of celiac trunk in children]

MATERIAL AND METHODS

For the period 2013-2016 four patients were treated at the Filatov Children's City Clinical Hospital #13. There were 2 children aged 14 years and 2 children aged 17 years. All patients have been diagnosed via anamnesis, complaints, pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. After comprehensive examination 3 patients underwent laparoscopic decompression of celiac trunk. In all cases celiac trunk compression was predominantly caused by median arcuate ligament of the diaphragm combined with neurofibrotic tissue of celiac plexus.

RESULTS

All patients were discharged after laparoscopic decompression of celiac trunk. Intra- and postoperative complications, as well as cases of conversion were absent. Mean time of surgery was 65 minutes. In all cases postoperative period was smooth (4 days on the average). Two patients underwent follow-up examination in long-term postoperative period: pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. In both cases reduced severity, incidence and duration of pain syndrome were observed.

CONCLUSION

Clinical examples show some problems in diagnosis and treatment of compressive stenosis of celiac trunk due to rarity of pathology especially in childhood. Nevertheless, combination of abdominal ischemia and celiac trunk stenosis confirmed by instrumental diagnosis is indication for surgical treatment.

Celiac Artery Compression Syndrome: Report of a Case and Review of Current Opinion

The celiac artery compression syndrome (or median arcuate ligament syn drome) is characterized by postprandial abdominal pain, an epigastric bruit, and arteriographic evidence of significant extrinsic compression of the celiac artery. Although the concept of extrinsic compression of vessels is well estab lished in vascular surgery, the existence of the celiac artery compression syn drome has been a matter of controversy. A patient relieved of celiac artery compression and postprandial pain is presented. A review of the controversy and an approach to evaluating patients suspected of having this type of com pression is outlined.

Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization

We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.

Treatment Options and Outcomes for Celiac Artery Compression Syndrome

Background. Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported. Methods. A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction. Results. Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence. Conclusion. In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.

Laparoscopic management of celiac artery compression syndrome

BACKGROUND

Celiac artery compression syndrome (CACS) remains a controversial diagnosis, despite several reported series documenting therapeutic efficacy of CA decompression. Traditional therapy consists of open surgical decompression, but since 2000, five isolated case reports have been published in which CACS has been successfully treated with laparoscopic techniques. This approach was adopted as the sole initial therapy for CACS at the Johns Hopkins Hospital in 2002. This article reports the results of a unique surgical series that triples the reported worldwide experience with this therapy.

METHODS

Fifteen patients (median age, 40.6 years) diagnosed with CACS underwent laparoscopic decompression by a single vascular surgeon. CACS was diagnosed by digital subtraction angiography in 14 patients and computed tomography (CT) angiography in one patient, with images acquired in both expiratory and inspiratory phases of respiration. CA decompression was offered after the results of a thorough workup for other pathology were negative, including upper and lower endoscopy, CT scanning, gastric and gallbladder emptying studies, upper gastrointestinal series, and small-bowel follow-through studies. Indications in all patients were abdominal pain and weight loss (average, 9 lbs). The procedure consisted of laparoscopic division of the median arcuate ligament and complete lysis of the CA from its origin on the aorta to its trifurcation.

RESULTS

Between November 2002 and September 2007, 15 consecutive patients underwent laparoscopic CA decompression. Median length of follow-up was 44.2 months. There were no operative deaths. Four patients were converted intraoperatively to an open decompression, all for intraoperative bleeding; only one required a blood transfusion. Average operating time was 189 minutes, and the average length of stay was 3.5 days. CA intervention was required in six patients, including three intraoperative procedures (1 patch angioplasty, 1 celiac bypass, 1 percutaneous angioplasty) and six late procedures (2 percutaneous angioplasties, 3 percutaneous stents, 1 celiac bypass). One complication occurred, a severe case of pancreatitis that developed 1 week after discharge. On follow-up, 14 of 15 patients subjectively reported significant improvement, and one patient remains symptomatic with no diagnosis.

CONCLUSION

Laparoscopic decompression of the CA may be a useful therapy for CACS, but there is potential for vascular injury, and adjunctive CA intervention is often required. Surgeons should consider laparoscopic CA decompression as a therapeutic alternative for CACS and should participate in the care of patients with this diagnosis.

Dunbar's syndrome and superior mesenteric artery's syndrome: a rare association

Celiac artery compression syndrome (CACS) and superior mesenteric artery syndrome (SMAS) are 2 rare diseases, widely described in literature. Their association has not been specifically investigated; in fact, few cases have been reported. For this reason we reviewed our experience from January 1974 to June 2004. We report 59 patients affected by CACS and 28 by SMAS. Coexistence of both syndromes in 8 patients was observed. These 8 patients were successfully treated with duodenojejunal bypass and decompression of the celiac trunk. In this paper, we analyze the pathogenesis, clinical presentation, diagnosis, and treatment of these syndromes, emphasizing their common aspects. The misdiagnosis of this association may justify in some cases the controversial results reported regarding the surgical treatment of these syndrome.

The anterior visceral branches of the abdominal aorta and their relationship to the renal arteries

Variations in the anatomy of the abdominal aorta and its branches are of interest as vessel geometry not only determines flow dynamics, but is also crucial in the pathogenesis of vascular disease. The relationship between the anterior visceral and renal arteries is important when undertaking diagnostic arteriography and endovascular interventions. To examine these relationships, the length of the abdominal aorta was determined and measurements taken of the position of origin of the celiac artery, superior mesenteric artery (SMA), inferior mesenteric artery (IMA) and renal arteries, as well as the three-dimensional projection of each vessel from the aorta. The mean level of bifurcation of the aorta was at the lower third of the body of L4, with the celiac artery, SMA, renal arteries and IMA arising at the level of the T12/L1 intervertebral disc, upper third of the body of L1, lower third of the body of L1 and lower third of the body of L3, respectively. The horizontal projection of the celiac artery, SMA and IMA was to the left of the midline; in the sagittal plane, the celiac artery and SMA projected anteriorly and the IMA posteriorly; in the coronal plane all vessels projected inferiorly, with the SMA to the right and the IMA to the left. The celiac artery, SMA and both renal arteries all arise from the proximal half of the abdominal aorta within 45 mm of each other, with the origins of the renal arteries being remarkably consistent. It is concluded that the celiac artery and SMA are both useful landmarks for determining the position of the renal arteries.

Exercise-related abdominal pain as a manifestation of the median arcuate ligament syndrome

Abdominal pain related to exercise, often loosely referred to as 'stitch', is not uncommon, particularly among participants in sports that involve running. The cause of this typically transient pain is poorly understood with several aetiologies proposed including diaphragmatic ischaemia (1, 2). Other gastrointestinal symptoms that are common during prolonged or high-intensity exercise include nausea, diarrhoea and gastrointestinal bleeding (3, 4). These symptoms are also usually transient and are thought to protect against critical organ damage by promoting cessation of exercise. Decreased gastrointestinal blood flow, increased motility and altered neuroendocrine modulation are postulated disease mechanisms (3). We report here a case of an elite runner with exercise-related severe abdominal pain and diarrhoea related to compression of the coeliac axis by the median arcuate ligament. Complete symptom relief was achieved with surgical division of the constricting ligament. The clinical characteristics and pathogenesis of coeliac axis compression syndrome are discussed.

Anatomical investigation of the esophageal and aortic hiatuses: physiologic, clinical and surgical considerations

Precise knowledge about the anatomical constitution of the diaphragmatic pillars is essential to understand the physiologic, clinical and surgical roles of the esophageal and aortic hiatuses. Because anatomical descriptions found in the literature are dubious, we have decided to investigate this subject. Anatomical dissections and histologic sections of the right and left diaphragmatic pillars (diaphragma crura) from 43 human bodies were analyzed, comprising both non-fixed and fixed specimens. We have described a classification of the diaphragmatic pillars and their muscular branches, forming two basic arrangements (patterns I and II) around the esophageal and aortic hiatuses. Such anatomical and functional relationships between the esophagus and its diaphragmatic hiatus help explain why, during normal inspiration, a hiatal enlargement is observed first but is followed, thereafter, during deep inspiration, by a hiatal narrowing exerted by the contraction of the diaphragmatic pillars. Our results also show that the aortic hiatus does not seem to constitute a rigid ventral tendinous arc around the aorta that could impose any considerable degree of vascular compression, as suggested by other investigators. The present study provides anatomical data useful for a better understanding of gastroesophageal reflux physiology, antireflux surgery and abdominal angina.

The use of gastric tonometry in the assessment of celiac artery compression syndrome

This report describes the use of gastric tonometry to measure gastric mucosal ischemia/intestinal mucosa pH (pHi) in a patient treated for celiac artery compression syndrome. Significant gastric mucosal ischemia was demonstrated prior to celiac artery decompression as indicated by a pHi of 7.29. The ischemia was relieved by celiac artery decompression, with an increase in the pHi to 7.48. The patient experienced complete relief of his symptoms after surgical decompression and remains asymptomatic 14 months after surgery. Gastric tonometry provides an objective measurement of intestinal perfusion and ischemia in the treatment of celiac artery compression syndrome.

Radiology in intestinal ischemia. Angiographic diagnosis and management

Angiography is an essential component of the diagnosis and treatment of patients with acute and chronic intestinal ischemia. Aortography and selective angiography permit identification of the cause and precise anatomy of intestinal ischemic syndromes, and also help plan their potential correction. Direct intra-arterial infusion of pharmacologic agents into splanchnic vessels has now become part of the therapy of these conditions. This article reviews angiographic techniques and their applications in the management of intestinal ischemic syndromes.

Would you recognize celiac axis syndrome?

Since its original description, celiac axis syndrome has been a topic of debate. Clinical findings include postprandial abdominal pain, weight loss, and an epigastric bruit. Diagnosis is often made by exclusion and is confirmed by lateral aortography. The role of surgery in treating celiac axis syndrome is controversial.

Coeliac artery compression syndrome: the effect of decompression

The effects of operation to decompress the coeliac artery were evaluated in 11 consecutive patients with coeliac artery compression syndrome. Immediately after the operation all patients were free of symptoms. Three months later three of the 11 had recurrent abdominal pain. Long-term follow-up between 15 and 23 years, obtained by questionnaire, was available for eight patients. All eight had return of symptoms similar to those before surgery. These unsatisfactory results suggest that operation should not be undertaken in patients with vague upper abdominal complaints and compression of the coeliac artery by the median arcuate ligament, who do not otherwise have pathological conditions which might explain their symptoms.